F0641

D

Inaccurate MDS Behavior Assessment for Resident With Verbal Aggression

San Rafael, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The facility failed to ensure an accurate MDS assessment for one resident when Section E of the MDS indicated the resident had no verbal behavior symptoms directed toward others, despite documentation and staff reports to the contrary. The resident had diagnoses of anxiety disorder and depression and was documented as having severe cognitive impairment on the MDS. A change of condition narrative note dated 1/9/26 described monitoring for increased yelling and verbal aggression toward staff, stating the resident continued to yell toward staff and her roommate. The resident’s MAR for January 2026 documented administration of antianxiety medication (Lorazepam) for behavior manifested by constant yelling causing exhaustion to self, with instructions to monitor behavior every shift.

During interviews, a licensed nurse who spoke Spanish reported that the resident cursed at her roommate in Spanish using very ugly, hateful words directed at the roommate. The MDS nurse stated he used various data sources for assessments, including observations, the electronic MAR, and nursing progress notes. Upon reviewing Section E of the resident’s MDS, he confirmed it showed no verbal behavior symptoms directed toward others, and upon reviewing the January MAR, he confirmed the resident was being monitored for yelling that caused exhaustion and had multiple episodes of yelling incidents. He acknowledged that yelling to exhaustion could meet the criteria of behaviors affecting others and stated he did not know why he did not identify this when completing the MDS, indicating he probably just missed it. Facility policy required that the RAI/MDS be completed accurately and used to guide individualized, resident-centered care planning and quality outcomes.